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My late uncle, in his youth. A life deserving of value.

Sarah Palin's "death panel" description polarized the nation; it was dismissed by proponents of the Patient Protection and Affordable Care Act (PPACA) as "pure demagoguery," and taken up by PPACA critics as a cudgel with which to pound "Obamacare."

I’d like to offer an intermediate perspective of sorts – one that recognizes PPACA isn’t calling for death panels, but also acknowledges why that concern seems especially salient.

The idea that our healthcare system can make dying with dignity difficult has been effectively communicated – see this poignant New Yorker piece by Atul Gawande, and this recent, heartbreaking New YorkMagazine article by Michael Wolff.

One take-away is that proactive discussions about end-of-life care, coupled with the ability of the health system to more effectively and more willingly implement these wishes, could be an unarguably good thing for patients and families. Moreover, in response to the “death panel” uproar, a provision for “voluntary advanced care planning” – a discussion about end-of-life preferences -- was removed as an element of the annual wellness visit for Medicare patients, even though it’s hard to see – especially in the context of the Gawande and Wolff pieces -- why this discussion in itself would be objectionable.

The anxiety about “death with dignity” comes when you start to layer in costs. For instance, there’s the frequently-invoked concern that a disproportionate amount of our healthcare dollar is spent on the last six months of life; many seem to believe that these dollars could be – and should be – more effectively spent.

Or, as Washington Post reader “leskruth” bluntly commented, “Americans are unwilling to die gracefully, even if it bankrupts their children’s and our future.”

This argument is also informed by bioethicists (mostly academic, it must be said, and mostly left-leaning), who often argue that the way our healthcare dollars are now spent is frequently market-driven and in any case fundamentally unethical; these scarce resources, they contend, should be allocated – redistributed? – in a more equitable fashion (see here for representative recent discussion).

Rationing is already occurring, they (and others) argue; we should acknowledge it and do it in a more sensible, ethical, and deliberate fashion. (And by the way, we’re happy to organize the committees you’ll need to help you do this.)

When you put these perspectives together, it sounds a lot like this: “The ethical solution to our current healthcare challenges is to try and redistribute spend from the elderly and the hopelessly sick to others who need it more, especially the underprivileged; this redistribution will require committees to make difficult decisions; bioethicists can be helpful here.”

I’ve always felt that the defining aspect of medicine was an impassioned advocacy for the patient in your care. This doesn’t mean ordering unnecessary tests, and it should include advanced planning discussions – but it also entails a commitment not to write off a patient in the name of a greater good.

Yes, a lot of money is spent on the last six months -- but this strikes me as more a statistical feature than anything else; what would an alternative spend distribution look like?

It’s important to recognize that first, we often don’t know just how near the end is, and second, even if we have a clear idea, then so what? If someone is diagnosed with late stage pancreatic cancer or certain types of brain tumors, should we tell them that for the good of society, please don’t rack up additional bills, the treatments probably won’t do much good anyway?